Inflammation of the Antrum.
As in the case of the frontal sinus, the clinical pathology of this cavity consists principally of suppuration, either free or retained. Free suppuration causes intra nasal symptoms, and this form is most frequently seen by the rhinologist. In suppuration with retention of pus from obstruction of the ostium maxillare, if the case is not already under the care of a rhinologist, a surgeon is usually con sulted. Finally, there is a special form of maxillary suppuration occurring in connection with dental caries which is usually cared for by the dentist. The result of this clinical subdivision is a partition of the literature of the sub ject, and somewhat contradictory ac counts of the causes, symptoms, etc., of this affection. Most rhinologists see but little of that form of suppuration caused by alveolar caries.
Symptoms.—A discharge of pus from the antrum flowing through the nasal passages produces sufficient irritation to cause localized congestion and swelling of the entire mucous surface; so that nasal obstruction is caused not only by the pus itself, but by the general swell ing of the mucous membrane. The pu rulent discharge varies in color and thick ness. During an acute exacerbation the discharge will be thin and perfectly yellow; when the symptoms subside, the pus becomes somewhat mixed with mu cus, and so is thicker and less highly colored. Unlike mucus or thin muco purulent secretion, a discharge of pus from the sinuses glues the handkerchief together. The discharge has little of the foetid odor noticed in a severe case of ortena, but the odor is so peculiar as hardly to be likened to anything else. The olfactory sense of the patient is not much blunted; so that he notices the odor more than does the patient suffer ing from different forms of caries of the nasal passages.
Diagnosis.—A unilateral discharge of pus from a nostril immediately suggests ethmoidal or antral suppuration, or both. Since, in our opinion, ethmoidal sup puration is the more common form of the two, it will be well to exclude this affection before deciding that the pus originates in the antrum. As has been said, it is not enough to find by trans illumination that a maxillary sinus is filled with pus to conclude even then that this is the primary trouble. We
may, perhaps, exclude ethmoidal sup puration by noting that there is no spe cial abnormality of the middle turbinated bone, no fungoid granulation or polypi, and that the probe cannot reach carious bone in the region of the middle meatus or ethmoidal cells. The fact that the pus enters the nostril from above or below the middle turbinated bone is not spe cially significant. A history of dental trouble, the location of pain about the cheek rather than over the supra-orbital ridge, will point to antral suppuration rather than to ethmoidal trouble. An other difference between the discharge from the antrum and that from the eth moidal cells is that, while in the latter the flow is quite constant, in the former pus is present in the nostrils when there is overflow or when the head is bent forward or carried to the side. The dis charge is more or less intermittent. The symptoms of pus confined in the antrum are much more positive, and are those of pressure and distension of the sinus and check. Sometimes the enlargement of the face on the affected side is very noticeable. There are cases where pus has been found by an exploratory needle passed through the middle meatus into the antrum in which the test of the elec tric light gave no symptoms.
Etiology.— The pyogenic bacteria I which cause antral suppuration may be accidentally present; repeated attacks of severe coryza, such as d occur when ob structive deformities are present, may, then, by extending into the sinus, rouse them to activity. In the severe types of infectious disease—such as scarlatina, measles, whooping-cough, and influenza —these specific germs may gain entrance into the antrum by extension along the inucosa, and incite an acute suppuration, which may persist as a purulent focus. Another frequent mode of origin would seem to be the following: Whenever pus is present in the middle meatus from any cause, and especially in connection with suppuration of the ethmoidal sinuses, it can readily drain into and infect the antrum. Extension of suppuration from the roots of carious teeth, as well as trauma of all sorts, disease of the supe rior maxillary bone, etc., also cause sup puration of the sinus.